In the last month I've published two pieces in the New York Times. One is about the underground resale market for diabetes test strips, which says a lot about the United States' byzantine healthcare system. The other is about a little-known program in New York City's arraignment courtrooms that has helped drive the jailed population to record lows.

For nearly a year I've been working on a story about an unprecedented legal battle between a New Mexico oncologist and the region's dominant hospital and insurer, which she alleges is trying to swallow up her practice. It's also a clash of views about how to organize our healthcare system. Published today in The New Republic.

Gun violence is a leading cause of injury death in the US yet few public health schools offer courses about it. So—with lots of help—I developed a curriculum and am teaching variations of it this fall Columbia and NYU.

I wrote my first article for The New York Times, about the long wait-times faced by people in need of liver transplants in some regions of the country, and the rocky efforts to reduce the inequities. Read it online.

I shot portraits of the incoming class of Henry Luce Scholars on the cusp of their departure to Asia. A diverse, inquisitive, and energetic group—and happy cannon fodder for my experiments with available light.

I reported a story published in the Lancet today about the Trans Pacific Partnership, one of the largest trade and investment agreements in recent memory that has implications for the price some consumers will pay for life-saving drugs, and the latitude by which states can fight to reduce tobacco use.

I spent a few hours tonight photographing the production team of the Vertigo Theater Company, who are putting on a series of original site-specific works at Gleason's Boxing Gym in downtown Brooklyn. The performances will be in late February 2015.

What we don’t know can kill us—confronting gun violence with data
In the United States, the intractable politics of gun violence prevention—and of gun violence itself—rest on a seeming contradiction: we give gun violence far more attention than other causes of preventable death, and yet we have learned far less about it.

A single murder will be recorded by dozens of state and federal agencies, can result in thousands of pages of police reports, and may make headlines and newscasts seen by millions. But hardly any of those data are harnessed or stitched together in a meaningful way to inform policies for preventing future deaths.

It’s hard to imagine achieving consensus about policies to prevent gun violence if we don’t first come to agreement about the underlying facts. Opponents of stronger gun laws recognized this in the early 1990s and turned it to their advantage, blocking access to public data and eliminating federal research on gun violence prevention—be it efforts to reduce firearm injury at the Centers for Disease Control and Prevention, or law enforcement analyses of guns recovered at crime scenes. Sadly, it worked: the volume of publications on gun violence prevention fell by 60% between 1996 and 2010, and efforts to improve our nation’s broken gun laws dwindled.

But this cuts deeper than politics: gun violence itself is exacerbated by deficits of information. A law abiding gun owner who transfers a firearm to a criminal in an unlicensed, “private,” sale may do so because there is no background check to inform them that the prospective buyer is prohibited from owning a gun. A court that fails to separate a domestic abuser from his firearms when issuing a protection order, may do so because there is no system in place to elicit information about whether the defendant owns a gun.

And citizens who are ignorant of the outside costs of gun violence—the expense of healthcare for victims, the downward pressure on property values in high crime neighborhoods, the long term psychological toll on children exposed to daily doses of gunfire— are not motivated to change it.

This is why, since its inception, Everytown for Gun Safety has fought for cities and law enforcement to maintain access to the best information available for combating illegal gun trafficking, and has championed increased funding for public health research on gun violence. Everytown’s own research has also paved the way for stronger gun laws in states across the country.

Scores of US cities have installed gunshot detection technology, which has the potential to identify and quantify illegal gunfire with a far greater sensitivity than public health or police data could previously provide.

A consortium of researchers led by the Chicago Crime Lab are studying the black market for guns in the country’s largest cities—combining trace data, social network analyses, surveys with prisoners, and community ethnographies—to yield a more nuanced understanding of how criminals in different cities obtain guns.

And journalists are using platforms such as Homicide Watch to track every murder in their cities, weaving stories of individual deaths into a more vivid tapestry of the phenomenon of fatal violence, and empowering the most affected communities to respond to it.

These transformative projects were highlighted at an event held during last week’s annual meeting of the American Public Health Association. Approaching the topic from the areas of public health, criminology, and journalism, the speakers shared a common goal: devising new methods to collect data, bundling it together to make it more meaningful, and returning it to decision makers to motivate action. Reflecting on the power of information, Homicide Watch’s co-founder Chris Amico said: “What I’d like to think is that we can change a person’s reality, we can change a person’s perception, we can change their understanding of the system. And maybe we can save someone.”

If gun violence is to be reduced in the US, it will happen not only because of actions in the halls of Congress, but because the landscape of information changed thanks to people like these.

As part of its 60th anniversary celebration, The Asia Foundation invited me to San Francisco for a public conversation with Monocle correspondent Alastair Gee about critical issues facing Asia in the 21st century and my photographic work. They produced a slideshow of some of my photography in China and also Indonesia.

I published two articles in this week’s Lancet on the difficult subject of sexual violence during armed conflict. The first is a feature exploring the factors that have brought the phenomenon to the attention of international lawmakers, and the limits of what is known about how to prevent it. The second is a profile of the courageous forensic doctor Muriel Volpellier, who is working with a team in the Democratic Republic of Congo to ensure victims get the care they need and perpetrators can be brought to justice.

Two articles I wrote this spring explore areas where the justice system and public health collide, to the detriment of both, —but where changes in approach are slowly bringing them into sync. For the first, I wrote about incarcerated juveniles, many of whom need treatment for mental illness more than time behind bars, and the Aichhorn residential treatment facility in Brooklyn that is trying to deliver those services to them. For the second, I wrote about the surge in heroin and prescription opiate overdose deaths afflicting the U.S., the difficult politics of the remarkable antidote naloxone, and novel approaches that the state of New Mexico has pioneered to make the drug more available.

Every year tobacco use kills more than a million people in China. And the company selling them that tobacco — the biggest cigarette manufacturer in the world — is owned and operated by their government. Small wonder its been hard to get public health authorities there to tamp down on the epidemic, but a new report by a major government thinktank suggests that change may be in the air, I reported in this month’s Lancet Respiratory Medicine.

I covered two infectious disease outbreaks in the last few months: fungal meningitis that spread from contaminated steroids at the New England Compounding Center, which represented one of the most damaging breakdowns of US drug safety in the past decade, and the outbreak of a novel strain of H7N9 avian influenza in China.

Nearly 32 years after China established its “One Child Policy”, the country’s leaders announced plans to dissolve the bureaucracy that oversees family planning and merge it with the Ministry of Health. Experts debate whether the change in institutions will result in liberalization of the country’s fertility policy itself, but it increasingly seems the end of the policy is not a question of “if” but “when.” I report in this week's Lancet.

When I lived in China I spent a month in a village in Sichuan where the economy revolved around huanglian, a root cultivated in the high mountains with medicinal properties. In this week’s Lancet Oncology I reported on how western pharmaceutical companies are trying to tap into the country’s wealth of traditional Chinese medicine for the development of new treatments.

In China, the public health response to diabetes and to cancer have both been transformed by the rapid economic development of the country and the shifting disease burden of its people. I reported on both of these stories over the last couple of months, first in The Lancet and then in The Lancet: Oncology:

New York City's life expectancy is rising faster than anywhere else in the USA, and at least some of the credit must go to Mayor Bloomberg's health department, which is pioneering tactics that could transform the practice of public health. I explore the implications in this week's Lancet.

Antibiotics are arguably the most important medical technology ever developed, and save thousands of human lives every day. But their biggest consumers in the USA are no longer people; they are livestock and poultry. And animals are not getting antibiotics just when they are sick; many of them are fed the drugs to get fat. My article in this month's Lancet: Infectious Diseases explains (subscriber link).

The report argues that existing regulations fail to prevent felons and other prohibited purchasers from buying guns online, and it documents undercover gun-purchases that took place in Ohio even after the buyer stated that he couldn't pass a background check:

To our knowledge, this is the first report to document the enormous number of guns available for purchase on the internet, and the paucity of effective oversight governing these online sales.

Two more articles I reported appeared in the The Lancet in recent weeks. For the first, on the persistence of China's 'One Child Policy' in the face of dwindling fertility and an aging population, I traveled to Yicheng County in Shanxi province, which has been governed by a unique two-child policy since the 1980s. The second article is about New Zealand's efforts to reduce the dramatic disparities in life expectancy and wellbeing that are exhibited by the indigenous Maori and non-Maori populations.

Earlier this year I traveled to Lincang in western Yunnan province to document the work of Teach For China, an NGO that hires dynamic recent-graduates from both US and Chinese universities to teach for two years in underserved areas of rural China.

Like most public services, education in China is hugely unequal, with resources and quality teachers channeled predominately to urban areas. Teach For China seeks to redress that. An affiliate of Teach For America, they recruit students from top universities, give them a crash-course in education (and for Americans amongst them, 普通话), and send them to some of the poorest areas of the country. The challenges they face there are immense but the work they are doing is profound. My still photographs were featured in their 2011 annual report:

And a promotional video I shot and produced (edited by Mandarin Films) is now online here:

I spent the last week in Tumen, Jilin Province, where a trickle of a river separates China from North Korea. The occasion for my visit was the Tumen River Festival: seven days of theater, music, and visual arts. My friend Shira Milikowsky was there with a troupe of her theater students from Kookmin University, Seoul, performing a musical entitled Jesse's Diary about the Korean independence movement, and an adaptation of Brecht's The Caucasian Chalk Circle re-set in 1953 South Korea, just after the UN armistice that stopped (but never officially ended) the Korean War. The setting, the performances, and the people were all magnificent.

I spent last month in New Zealand, reporting a story on the disparities in health between the Maori- and European-descended peoples there, amongst other things. It afforded me the chance to experience a month of winter in July.

In Mongolia’s National Cancer Center, an imposing cement structure in Ulaanbaatar, a patient named Chantsal was recovering from surgery. A retired radiology tech, it was a matter of chance that had brought him in for a screening. “It was my children’s vacation so I took them there for a dental checkup, and I just thought that I should do an ultrasound check.” The exam revealed a large tumor on his liver.

Mongolia has the world’s highest rate of liver cancer mortality—six times the global average—and the number is climbing. In this context Chantsal was a relatively fortunate case; by the time most Mongolians with hepatocellular carcinoma (HCC) are diagnosed, their disease is already inoperable. This was the case for Chantsal’s brother when he developed liver cancer two years ago. “He was working in the countryside at that time and the only doctors he had were the soum [district] doctors and then he just died,” Chantsal recalled. The surgeons at the National Cancer Center, where nearly all the country’s cases are referred after diagnosis, estimate that only 10% of Mongolians diagnosed with HCC are identified early enough to be eligible for surgery.

No one is more aware of the burden of liver cancer in Mongolia than Mongolians themselves. “Every family has lost someone to HCC,” says Tsendsuren Oyunsuren, a leading researcher into the Mongolian epidemic. Her grandmother and father died of HCC, which inspired her to enter the field. Mongolia’s political class is not immune, either. In 2009, Prime Minister Bayar Sanjaa announced that he was a carrier of hepatitis C, and he ultimately resigned from office to seek medical treatment.

HCC accounts for nearly half of cancer mortality in Mongolia. At the WHO’s last measure, one of every ten deaths in the country was due to HCC or its frequent precursor, cirrhosis. In turn, nearly all Mongolians suffering from liver disease carry hepatitis B or C viruses or both, and researchers agree that those infections are the main causes of liver disease in the country. More than a quarter of Mongolians are chronic carriers of at least one of the viruses, and almost none are aware of their status.

The Asian region has historically been burdened with a high prevalence of hepatitis B so Mongolia is not an outlier in this regard. A national childhood vaccination campaign, initiated in 1991, has protected younger cohorts from the virus and holds the promise of eliminating it from the country over the next generation.

It is the additional burden of hepatitis C, for which no vaccine currently exists, that distinguishes Mongolia from the rest of Asia. Although unsafe surgical procedures and dental practices are thought to play a role, much remains unclear about the virus’s origins in the country and the mechanisms of its continuing transmission. Absent a solid understanding of this epidemiology, the country’s hepatitis C prevalence continues to rise. Alcohol use, which hastens progression to cirrhosis for those with concurrent viral infection, is also widespread in Mongolia, compounding the epidemic.

Chronic carriers of either virus are usually asymptomatic for decades but face a great risk of developing cirrhosis and HCC over their lifetimes. So even if new cases of hepatitis in Mongolia are curtailed, the high proportion of people already carrying the viruses portends a sustained increase in the burden of liver disease. “This won’t just last five more years,” asserts Tsiiregzen Enkhamgalan, one of a handful of the country’s hepatobiliary surgeons tasked with treating these patients. “We expect forty more years to face the same conditions.”

The global health community has given little attention to liver disease relative to other public health issues, and Mongolia’s experience is no exception. "The utmost priority is given to HIV, TB, and infectious diseases such as avian influenza," commented Zolbayar Ganbold, an officer in the Ministry of Health's division of international cooperation. "Viral hepatitis and liver disease are very much less targeted."

UN agencies support a set of burgeoning HIV programs in Mongolia although as of 2009 the cumulative total of AIDS cases there numbered just 62. And the United States’ Millennium Challenge Account has recently begun supplying significant funding for non-communicable diseases, but their compact focuses on breast and cervical cancer and makes no mention of HCC.

Still poor by global standards, Mongolia is thus in the challenging position of dealing with a heavy burden of non-communicable disease that is more typical of the developed world, and which demands a rich country’s resources and functioning health system.

The Mongolian Government plans to strengthen the health system to address non-communicable diseases. “We are making some organizational and strategy changes because we have to improve early detection and control of non-communicable diseases, including liver disease, at the primary health care level,” says Gombodorj Tsetsegdari, a senior officer in the Ministry of Health. But such changes will be a challenge, and the extensiveness of the Mongolian countryside is daunting. It is the least densely populated independent country on earth, and 60% of the population resides outside the capital.

Even if diagnostics improve, it isn’t clear what treatments will be readily available. Ideally, carriers of viral hepatitis would be identified and treated long before the infection damaged their livers irreparably. But neither antiviral treatment for hepatitis B nor interferon-based therapy for hepatitis C are presently covered by the national health system, and their high price puts them well out of the reach of most Mongolians. “Treatment is very, very costly,” Tsetsegdari says. “That’s why we don’t have [them].”

Even for services that the public system covers, much of the financial burden ultimately falls on patients. In regards to surgery at the National Cancer Center, Enkhamgalan explains: “the government says that all cancer care is under the control of government, that all costs related to cancer care come from the government. But the government doesn’t give a sufficient amount of money to pay for them.” He estimates that patients must defray about 80% of the cost of imaging tests, surgical equipment, and sutures. Perversely, non-surgical therapies such as radio frequency ablation or transcatheter arterial chemoembolization are rarely utilized at all because those procedures are not covered by insurance, even though they are less invasive than surgery and are associated with better outcomes for some patients.

In wealthier countries, all these treatments serve primarily as bridges to liver transplantation, but in Mongolia they are themselves the last recourse. A few Mongolian physicians dream of beginning a transplant program in the country, but most acknowledge that it’s not realistic in the short term. “[Transplantation] is like the diamond in the crown,” said VSO country director Indermohan Narula, who has been a technical adviser to the Ministry of Health since 1995. “It’s just decorative; it’s too expensive to actually manage.”

By necessity, then, Mongolia has turned to palliative care as a final but valuable service for its terminal cancer patients, and with noteworthy success. The National Cancer Center established a palliative care wing in 2000 but additional policy changes were needed to make the necessary drugs and manpower available. Tserendorj Gantuya, now its chief palliative care physician, began working on the wing eight years ago. “I always remember how before 2006 it was so difficult, how my job made me so nervous. Every day we received patients with really, really severe pain and we didn’t have any painkillers and the doctors didn’t know how to relieve the pain. And the patient’s caregiver was so nervous because the patient had severe pain and the doctor couldn’t do anything.”

Outside parties, particularly the Open Society Institute, supported local advocates as they integrated palliative care into the national health care system. In 2005, importation quotas for injectable and oral morphine formulations were greatly increased, and national standards for their use were issued. Reformers also added palliative care to undergraduate medical education and initiated a four-year course for social workers.

The workload of the palliative care wing has expanded, as has their staff. “In 2003, we received only 100 patients a year,” recalls Gantuya. “Now in the inpatient unit alone we see 700 patients, and in the ambulatory service we see another fourteen patients every day.” Where once they employed just two doctors and six nurses, the staff now includes three doctors, eleven nurses, a dietician, a pharmacist, and a social worker. Several private hospices have also sprung up in Ulaanbaatar, mostly operated by missionary groups.

But these services are few compared to the scale of the county’s needs. Palliative care is not yet widely available outside of the capital, so patients must often travel great distances for treatment. At Hope Hospice, one such family hovered anxiously around the ashen figure of their father, who was dying of HCC. Herders by trade, they had journeyed over a thousand kilometers to bring him to Ulaanbaatar for care, pulling their children from school and leaving their livestock in the care of friends.

Advocates of palliative care hope to soon close some of those gaps. Mongolia’s health insurance law was recently revised to begin reimbursing district hospitals for palliative services so that patients can obtain care closer to home. Cancer Free Mongolia, an organization founded by first lady Bolormaa Khajidsuren, has since established a model palliative care facility in one of Mongolia’s six districts, and the Ministry of Health has promised to set up comparable services in the others soon. And in March of 2011, physicians across the country will participate in a formal training on pain-management. “Family doctors can prescribe morphine, but they don’t know how to use it so they are anxious,” Gantuya opines. “After the training, I hope they will have more confidence.”

For now, though, needy patients outnumber spaces and the palliative care wing must limit inpatient stays to ten days. HCC cases fill two-thirds of their beds and, barring a breakthrough in the way that viral hepatitis is diagnosed or treated, conditions are likely to remain this way. For the foreseeable future, then, dying in a peaceful place and free of pain may be the most that Mongolian HCC patients can hope for.

Last week I was in central Java, Indonesia, documenting a development project funded by The Asia Foundation that seeks to promote tolerance and other civil values in secondary schools.

The majority of Indonesians are muslim, a fact reflected by every aspect of daily life. Mosques are woven into the urban landscape, and calls to prayer mark the hours of the day. But other beliefs make up significant minority groups in the country and for centuries there has been room for a diversity of practices. Our driver was emblematic of this amalgam -- a Christian convert, his children profess different faiths, and on Friday nights he lets the crowd from the neighborhood mosque spill into his yard.

Given these events, the work of The Asia Foundation seems prescient. Working with local partners, they are training teachers in rural Islamic schools and giving them new ways to incorporate simple values like tolerance and equality into their curriculums. We visited schools where the program was being implemented, speaking with teachers and students. There's no single way to resolve deep tensions between different groups, but its clear that reaching out to youth is an important part. A selection of images can be viewed here.